Type of social support among homeless women: its impact on psychosocial resources, health and health behaviors, and use of health services

Multiple Disadvantage and Social Networks: Toward an Integrated Theory of Health Care Use During Reentry From Criminal Justice Settings

Research consistently finds the disproportionate negative health impact of the criminal justice system on racial and ethnic minorities. Yet less is known about the underlying mechanisms of health care utilization during community reintegration. We contribute to the literature theoretically by integrating two perspectives: network theory of social capital and multiple disadvantage hypothesis and providing a more nuanced explanation of health service use during reentry. We identify incarceration history as a unique disadvantaged status that precludes people from accessing social networks and social capital. We further elaborate on the phenomenon of racialized reentry and illustrate how multiple disadvantaged statuses are linked to social networks and health care.

The Association of Interpersonal Relationships and Social Services with the Self-Rated Health of Spanish Homelessness

Understanding the specific factors associated with poor health is critical to improve the health of homeless people. This study aimed to analyze the influence of personal variables, interpersonal relationships, and the influence of social services on the health of homeless people. A secondary analysis was applied to cross-sectional data from a sample of 1382 homeless people living in the Basque Country (Spain) (75.69% male). Multinomial logistic regression modelling was used to analyze the relationship between health and personal variables, interpersonal variables, perceived help and use of the social services. Relationships with the family, using a day center, and a sufficient and high perceived help of the social services were significant factors associated with good health. On the other hand, spending the day alone or using mental and health care services are associated with poor health. In the same way, the longer a person has been homeless, the worse their expected state of health is. Addressing housing exclusion, promoting interpersonal relationships, using a day center, and developing the use and perceived helpfulness of social services stand out as key factors in improving health status. Social policies are usually focused on housing. However, this paper also highlights the relevance of developing interpersonal relationships and using day centers to improve homeless people’s health.

Providing Appropriate Pancreatic Cancer Care for People Experiencing Homelessness: A Surgical Perspective

People experiencing homelessness are particularly vulnerable when diagnosed with pancreatic cancer. Patients with lower socioeconomic status have worse outcomes from pancreatic cancer as the result of disparities in access to treatment and barriers to navigation of the health care system. Patients with lower socioeconomic status, or who are vulnerably housed, are less likely to receive surgical treatment even when it is recommended by National Comprehensive Cancer Network guidelines. This disparity in access to surgical care explains much of the gap in pancreatic cancer outcomes. There are many factors that contribute to this disparity in surgical management of pancreatic cancer in people experiencing homelessness. These include a lack of reliable transportation, feeling unwelcome in the medical setting, a lack of primary care and health insurance, and implicit biases of health care providers, including racial bias. Solutions that focus on rectifying these problems include utilizing patient navigators, addressing implicit biases of all health care providers and staff, creating an environment that caters to the needs of patients experiencing homelessness, and improving their access to insurance and regional support networks. Implementing these potential solutions all the way from the individual provider to national safety nets could improve outcomes for patients with pancreatic cancer who are experiencing homelessness.

Urban Stress Indirectly Influences Psychological Symptoms through Its Association with Distress Tolerance and Perceived Social Support among Adults Experiencing Homelessness

Traditionally, intrapersonal characteristics (distress tolerance) and interpersonal characteristics (social support) have been studied separately rather than simultaneously. In the current study, we address this gap by simultaneously examining these characteristics as potential indirect associations linking established urban stress-depression and urban stress-Post-Traumatic Stress Disorder (PTSD) relationships. Adults experiencing homelessness were recruited from six homeless shelters in Oklahoma City (n = 567). Participants self-reported urban life stress (Urban Life Stress Scale), distress tolerance (Distress Tolerance Scale), social support (Interpersonal Support Evaluation List 12), major depressive disorder (Patient Health Questionnaire-8), and PTSD symptoms (Primary Care Post-Traumatic Stress Disorder screener). Covariate-adjusted structural equation models indicated a significant indirect effect of distress tolerance on the urban stress-depression (b = 0.101, 95% CI = 0.061, 0.147) and urban stress-PTSD (b = 0.065, 95% CI = 0.023, 0.112) relationships. Additionally, a significant indirect effect of social support on the urban stress-depression (b = 0.091, 95% CI = 0.053, 0.133) and urban stress-PTSD relationships (b = 0.043, 95% CI = 0.006, 0.082) was evident. Further, both the urban stress-depression (b = 0.022, 95% CI = 0.011, 0.037) and urban stress-PTSD relationships (b = 0.014, 95% CI = 0.005, 0.026) were associated indirectly through social support to distress tolerance. Interventions that aim to increase social support may also increase distress tolerance skills and indirectly reduce depressive and PTSD symptoms in the context of urban stress among adults experiencing homelessness.

The Particularly Vulnerable Situation of Women Living Homeless in Madrid (Spain)

People in homeless situation are one of the major embodiments of the phenomenon of social exclusion, and women living homeless are considered a particularly vulnerable group. This paper examines different variables that may affect the situation of vulnerability experienced by women living homeless in Madrid (Spain). The study was carried out using data obtained from a representative sample of homeless men in Madrid (n = 158) and a sample of homeless women in Madrid of a similar size (n = 138). The information was gathered using a structured interview in shelters or other facilities for people in a homeless situation, on the street and in other places not initially designed for sleeping. The results show that woman living homeless are highly vulnerable compared to the domiciled population and, in some respects, to homeless men as well, especially in the number of times homeless (χ2 = 10.314; p < .01), in the time working with a contract and/or self-employed (t = 5.754; p < .001), and in the use of sedatives (χ2= 14.741; p < .001). It is however noted that homeless women show in some aspects greater strengths than homeless men. Such strengths could serve as a supporting point for their social inclusion processes. The analysis of issues that differentiate women in a homeless situation from their male counterparts could be useful for developing public policies and care resources adapted to the specific characteristics and needs of women living homeless.

Social support and housing transitions among homeless adults with serious mental illness and substance use disorders

OBJECTIVE

Research suggests that social supports are associated with housing retention among adults who have experienced homelessness. Yet, we know very little about the social support context in consumers find and retain housing. We examined the ways and identified the junctures in which consumers' skills and deficits in accessing and mobilizing social supports influenced their longitudinal housing status.

METHOD

We performed semi-structured qualitative interviews with VA Greater Los Angeles consumers (n = 19) with serious mental illness, substance use disorders, and a history of homelessness; interviews explored associations between longitudinal housing status (categorized as: stable, independent housing; sheltered housing, continually engaged in structured housing programs; and unstable housing) and social supports. We compared data from consumers in these 3 mutually exclusive categories.

RESULTS

All participants described social support as important for finding and maintaining housing. However, participants used formal (provider/case managers) and informal (family/friends) supports in different ways. Participants in stable housing relied on formal and informal supports to obtain/maintain housing. Participants in sheltered housing primarily used formal supports, for example, case management staff. Unstably housed participants used formal and informal supports, but some of these relationships were superficial or of negative valence. Interpersonal problems were prevalent across longitudinal housing status categories.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Social context, including patterns of formal and informal support, was associated with participants' longitudinal housing status. Within interventions to end homelessness, these findings suggest the value of future research to identify, tailor, and implement practices that can help consumers improve their social resources. (PsycINFO Database Record

Changes in Social Exclusion Indicators and Psychological Distress Among Homeless People Over a 2.5-Year Period

Although homelessness is inherently associated with social exclusion, homeless individuals are rarely included in conventional studies on social exclusion. Use of longitudinal survey data from a cohort study on homeless people in four major Dutch cities (n = 378) allowed to examine: changes in indicators of social exclusion among homeless people over a 2.5-year period after reporting to the social relief system, and associations between changes in indicators of social exclusion and changes in psychological distress. Multinomial logistic regression analysis was applied to investigate the associations between changes in indicators of social exclusion and changes in psychological distress. Improvements were found in various indicators of social exclusion, whereas financial debts showed no significant improvement. Changes in unmet care needs, health insurance, social support from family and relatedness to others were related to changes in psychological distress. This study demonstrated improvements in various indicators of social exclusion among homeless people over a period of 2.5 years, and sheds light on the concept of social exclusion in relation to homelessness.

Dutch homeless people 2.5 years after shelter admission: what are predictors of housing stability and housing satisfaction?

Housing stability is an important focus in research on homeless people. Although definitions of stable housing differ across studies, the perspective of homeless people themselves is generally not included. Therefore, this study explored the inclusion of satisfaction with the participant's current housing status as part of the definition of housing stability and also examined predictors of housing stability with and without the inclusion of homeless person's perspective. Of the initial cohort consisting of 513 homeless participants who were included at baseline in 2011, 324 (63.2%) were also interviewed at 2.5-year follow-up. To determine independent predictors of housing stability, we fitted multivariate logistic regression models using stepwise backward regression. At 2.5-year follow-up, 222 participants (68.5%) were stably housed and 163 participants (51.1%) were stably housed and satisfied with their housing status. Having been arrested (OR = 0.36, 95% CI: 0.20-0.63), a high level of somatisation (physical manifestations of psychological distress) (OR = 0.52, 95% CI: 0.30-0.91) and having unmet care needs (OR = 0.77, 95% CI: 0.60-0.99) were negative predictors of housing stability. Having been arrested (OR = 0.43, 95% CI: 0.25-0.75), high debts (OR = 0.45, 95% CI: 0.24-0.84) and a high level of somatisation (OR = 0.49, 95% CI: 0.28-0.84) were negative predictors of stable housing when satisfaction with the housing status was included. Because inclusion of a subjective component revealed a subgroup of stably housed but not satisfied participants and changed the significant predictors, this seems a relevant addition to the customary definition of housing stability. Participants with characteristics negatively associated with housing stability should receive more extensive and individually tailored support services to facilitate achievement of housing stability.

The State of Measurement of Self-Esteem of African American Women

This article critically reviews the state of measurement of self-esteem in African American women. The Rosenberg Self-Esteem Scale, the Tennessee Self-Concept Scale, and the Coopersmith Self-Esteem Inventory are three commonly used measures. However, their validity for African American women has not been adequately tested. Given the unique nature of the self-esteem of this group, related to experiences of racism and sexism, the accurate measurement of this construct is important. This review provided support for the internal consistency of each measure with alpha coefficients ranging from .74 to .87. However, the validity of the measures was not fully supported. Suggestions for further research specific to the unique needs of this population are discussed.

Correlates of Sex Trading among Drug-Involved Women in Committed Intimate Relationships: A Risk Profile

BACKGROUND

Despite a slight decline in new human immunodeficiency virus (HIV) infections in New York, marked increases and concentrated epidemics continue among subsets of the population, including women engaged in sex trading. We examined the prevalence and correlates of sex trading among 346 low-income, HIV-negative women in HIV-concordant intimate relationships.

METHODS

Women and their long-term main partners were recruited to participate in an HIV prevention intervention. Baseline data were used in this article.

FINDINGS

Of the 346 women in the study, 28% reported sex trading during the prior 90 days. Multivariate analyses showed increased relative risk of sex trading by lifetime experience of severe intimate partner violence (IPV), drug, and alcohol use, and marginal significance for mental health hospitalization, partner drug dependency, and homelessness.

CONCLUSIONS

These findings suggest an urgent need for HIV prevention and intervention efforts targeted toward women in intimate relationships who trade sex for money or drugs, with an emphasis on IPV, mental health, history of incarceration, and substance abuse.

Factors affecting exits from homelessness among persons with serious mental illness and substance use disorders

OBJECTIVE

We sought to understand the housing trajectories of homeless consumers with serious mental illness (SMI) and co-occurring substance use disorders (SUD) and to identify factors that best predicted achievement of independent housing.

METHOD

Using administrative data, we identified homeless persons with SMI and SUD admitted to a residential rehabilitation program from December 2008 to November 2011. Our primary outcome measure was independent housing status. On a random sample (N = 36), we assessed a range of potential predictors of housing outcomes, including symptoms, cognition, and social/community supports. We used the Residential Time-Line Follow-Back (TLFB) Inventory to gather housing histories since exiting rehabilitation and to identify housing outcomes. We used Recursive Partitioning (RP) to identify variables that best differentiated participants by these outcomes.

RESULTS

We identified 3 housing trajectories: stable housing (n = 14), unstable housing (n = 15), and continuously engaged in housing services (n = 7). In RP analysis, 2 variables (Symbol Digit Modalities Test [SDMT], a neurocognitive speed of processing measure, and Behavior and Symptom Identification Scale [BASIS-24] Relationships subscale, which quantifies symptoms affecting relationships) were sufficient to capture information provided by 26 predictors to classify participants by housing outcome. Participants predicted to continuously engage in services had impaired processing speeds (SDMT score < 32.5). Among consumers with SDMT score ≥ 32.5, those predicted to achieve stable housing had fewer interpersonal symptoms (BASIS-24 Relationships subscale score < 0.81) than those predicted to have unstable housing. This model explains 57% of this sample's variability and 14% of this population's variability in housing outcomes.

CONCLUSIONS

Because cognition and symptoms influencing relationships predicted housing outcomes for homeless adults with SMI and SUD, cognitive and social skills training may be useful for this population.

Substance use trends among younger vs. older homeless parolees

This cross-sectional study of 540 homeless ex-offenders exiting prisons and jails assessed sociodemographic, childhood, and drug-related differences. Older ex-offenders from prison were more likely to have been married, come from a two-parent family, and used crack, whereas younger ex-offenders from prison were more likely to have used methamphetamine. Older ex-offenders from jail were more likely to be African American, have children, and report a history of crack and injection drug use, whereas younger ex-offenders from jail were more likely to have engaged in binge drinking and be in a gang. Our findings showcase the need to understand unique correlates of younger and older incarcerated populations.

Use of counselling services by school-attending adolescent girls in Nigeria

PURPOSE

The purpose of this study was to examine the predictors and barriers to the use of school counselling services by school attending adolescent girls in south-east Nigeria.

METHOD

The study used a cross-sectional survey of 3065 adolescent girls, using a self-report counselling utilisation scale. Data were analysed using both descriptive and inferential statistics.

RESULTS

About 80% of the participants had school counsellors and nearly half of the participants utilised the service. Regression results showed that father's level of education, availability of a counselling laboratory/room, contentment with the counselling services rendered predicted the use of the counselling service. Some of the barriers for non-use of school counselling services were shyness, fear and lack of confidentiality.

CONCLUSION

School authorities will encourage uptake of counselling services by adolescents when adequate counselling consulting rooms are provided. This will increase confidence in adolescent clients and reduce fear attached to use of these services. This will improve their mental health and their academic performance.

Associations between social support and condom use among commercial sex workers in China: a cross-sectional study

Objective

The aim of this study was to investigate the association between social support and AIDS high-risk behaviors in commercial sex workers (CSWs) in China.

Methods

A cross-sectional study was performed based on a convenience sample. Data were collected through questionnaire interviews including information about social demographic characteristics, the Social Support Rating Scale (SSRS) and AIDS knowledge. Multiple logistic regression was performed to evaluate the association between social support and AIDS high-risk behaviors, specifically condom use during commercial sex.

Results

A total of 581 commercial sex workers from 4 counties in East China participated in the study. The majority of the participants were 15 to 30 years old (79.7%). Sources of individual and family support were mainly provided by their parents (50.3%), relatives and friends (46.3%), spouses (18.4%), respectively. Univariate analysis revealed that marital status, hobbies, smoking habit, individual monthly income and family monthly income were all significantly correlated with current levels of social support being received (P = 0.04, P = 0.00, P = 0.01, P = 0.01, P = 0.01, respectively). Furthermore, Multiple logistic regression analysis indicated that after adjusting for confounding factors, high levels of social support were significantly correlated with increased condom use at the last sexual encounter (P = 0.02, OR = 1.86, 95%CI: 1.10–3.16); and consistently in the past month with clients (P = 0.03, OR = 2.10, 95%CI: 1.09–4.04).

Conclusion

CSWs with high levels of social support are more likely to use condoms during commercial sex. This suggests that increasing social support can potentially reduce AIDS-related high-risk behaviors and accordingly play an important role in AIDS prevention.

Correlates of Heroin and Methamphetamine Use among Homeless Male Ex-Jail and Prison Offenders

Homeless men exiting California State jails and prisons are a heterogeneous community with varied childhood, incarceration and drug use histories. This cross-sectional study assessed whether homeless men who were discharged from either jail or prison into a residential substance abuse treatment program, differed in terms of methamphetamine and heroin use. This study utilized baseline data collected on 540 recently paroled men randomized to one of three programs that assessed the impact of a peer coaching intervention on subsequent drug use and re-incarceration. We found that younger ex-offenders exiting prisons and jails were more likely to have used methamphetamine alone, whereas African American ex-offenders were less likely to have used methamphetamine alone when compared to other ethnic groups. Further, ex-offenders exiting jails and self-reporting use of heroin only at baseline were significantly more likely than their counterparts to have been removed from home before age 18. For men exiting jails, there was an association between lower self-esteem and having used methamphetamine but not heroin. However, having used both heroin and methamphetamine was associated with both violent crime and cognitive problems in both jail and prison samples. Our findings showcase the need to understand unique correlates of both heroin and methamphetamine as they relate to jail and prison populations.

Predisposing, enabling and need correlates of mental health treatment utilization among homeless men

There is significant unmet need for mental health treatment among homeless men, but little is known about the correlates of treatment utilization in this population. Within the framework of the Behavioral Model for Vulnerable Populations, this study examines predisposing, enabling and need factors that may be associated with mental health care utilization. Participants were a representative sample of 305 heterosexually active homeless men utilizing meal programs in the Skid Row region of LA. Logistic regression examined the association between predisposing, enabling and need factors and past 30 day mental health service utilization on Skid Row. Results indicated that while need, operationalized as positive screens for posttraumatic stress disorder or depression, was associated with recent mental health care utilization, predisposing and enabling factors were also related to utilization. African-American homeless men, and those men who also reported substance abuse treatment and drop-in center use, had increased odds of reporting mental health care utilization.

Correlates of risky alcohol and methamphetamine use among currently homeless male parolees

Homeless men on parole are a hard-to-reach population with significant community reintegration challenges. This cross-sectional study describes sociodemographic, cognitive, psychosocial, and drug-related correlates of alcohol and methamphetamine use in 157 homeless male parolees (age range 18-60) enrolled in a substance abuse treatment center in Los Angeles, California. Logistic regression results revealed that being African American and older were negatively related to methamphetamine use, whereas being older and more hostile were related to riskier alcohol abuse. Findings from this study provide a greater understanding of correlates of methamphetamine and alcohol--two of the most detrimental forms of substances abused among currently homeless parolees.

Social support and HIV-related risk behaviors: a systematic review of the global literature

Existing empirical evidence has well documented the role of social support in both physical and psychological well-being among various populations. In the context of HIV prevention, the rapid increase of studies on social support merits a systematic review to synthesize the current global literature on association between social support and HIV-related risk behaviors. The current review reveals a complex picture of this relationship across diverse populations. Existing studies indicate that higher levels of social support are related to fewer HIV-related risk behaviors among female sex workers and people living with HIV/AIDS and heterosexual adults in general. However, influences of social support on HIV-related risk behaviors are inconsistent within drug users, men who have sex with men and adolescents. These variations in findings may be attributed to different measurement of social support in different studies, specific context of social support for diverse population, or various characteristics of the social networks the study population obtained support from. Future studies are needed to explore the mechanism of how social support affects HIV-related risk behaviors. HIV prevention intervention efforts need to focus on the positive effect of social support for various vulnerable and at-risk populations. Future efforts also need to incorporate necessary structure change and utilize technical innovation in order to maximize the protective role of social support in HIV risk prevention or reduction.

Single room occupancy (SRO) hotels as mental health risk environments among impoverished women: the intersection of policy, drug use, trauma, and urban space

BACKGROUND

Due to the significantly high levels of comorbid substance use and mental health diagnosis among urban poor populations, examining the intersection of drug policy and place requires a consideration of the role of housing in drug user mental health. In San Francisco, geographic boundedness and progressive health and housing polices have coalesced to make single room occupancy hotels (SROs) a key urban built environment used to house poor populations with co-occurring drug use and mental health issues. Unstably housed women who use illicit drugs have high rates of lifetime and current trauma, which manifests in disproportionately high rates of post-traumatic stress disorder (PTSD), anxiety, and depression when compared to stably housed women.

METHODS

We report data from a qualitative interview study (n=30) and four years of ethnography conducted with housing policy makers and unstably housed women who use drugs and live in SROs.

RESULTS

Women in the study lived in a range of SRO built environments, from publicly funded, newly built SROs to privately owned, dilapidated buildings, which presented a rich opportunity for ethnographic comparison. Applying Rhodes et al.'s framework of socio-structural vulnerability, we explore how SROs can operate as "mental health risk environments" in which macro-structural factors (housing policies shaping the built environment) interact with meso-level factors (social relations within SROs) and micro-level, behavioral coping strategies to impact women's mental health. The degree to which SRO built environments were "trauma-sensitive" at the macro level significantly influenced women's mental health at meso- and micro-levels. Women who were living in SROs which exacerbated fear and anxiety attempted, with limited success, to deploy strategies on the meso- and micro-level to manage their mental health symptoms.

CONCLUSION

Study findings underscore the importance of housing polices which consider substance use in the context of current and cumulative trauma experiences in order to improve quality of life and mental health for unstably housed women.

Predictors of substance abuse treatment participation among homeless adults

The current study focuses on the relationships among a trauma history, a substance use history, chronic homelessness, and the mediating role of recent emotional distress in predicting drug treatment participation among adult homeless people. We explored the predictors of participation in substance abuse treatment because enrolling and retaining clients in substance abuse treatment programs is always a challenge particularly among homeless people. Participants were 853 homeless adults from Los Angeles, California. Using structural equation models, findings indicated that trauma history, substance use history and chronicity of homelessness were associated, and were significant predictors of greater recent emotional distress. The most notable result was that recent emotional distress predicted less participation in current substance abuse treatment (both formal and self-help) whereas a substance use history alone predicted significantly more participation in treatment. Implications concerning treatment engagement and difficulties in obtaining appropriate dual-diagnosis services for homeless mentally distressed individuals are discussed.

The effectiveness of critical time intervention for abused women and homeless people leaving Dutch shelters: study protocol of two randomised controlled trials

Background

One of the main priorities of Dutch organisations providing shelter services is to develop evidence-based interventions in the care for abused women and homeless people. To date, most of these organisations have not used specific intervention models and the interventions which have been implemented rarely have an empirical and theoretical foundation. The present studies aim to examine the effectiveness of critical time intervention (CTI) for abused women and homeless people.

Methods

In two multi-centre randomised controlled trials we investigate whether CTI, a time-limited (nine month) outreach intervention, is more effective than care-as-usual for abused women and homeless people making the transition from shelter facilities to supported or independent housing. Participants were recruited in 19 women’s shelter facilities and 22 homeless shelter facilities across The Netherlands and randomly allocated to the intervention group (CTI) or the control group (care-as-usual). They were interviewed four times in nine months: once before leaving the shelter, and then at three, six and nine months after leaving the shelter. Quality of life (primary outcome for abused women) and recurrent loss of housing (primary outcome for homeless people) as well as secondary outcomes (e.g. care needs, self-esteem, loneliness, social support, substance use, psychological distress and service use) were assessed during the interviews. In addition, the model integrity of CTI was investigated during the data collection period.

Discussion

Based on international research CTI is expected to be an appropriate intervention for clients making the transition from institutional to community living. If CTI proves to be effective for abused women and homeless people, shelter services could include this case management model in their professional standards and improve the (quality of) services for clients.

Trial registration

NTR3463 and NTR3425

Social support networks and primary care use by HIV-infected drug users

HIV-infected current and former drug users utilize primary care and preventive health services at suboptimal rates, but little is known about how social support networks are associated with health services use. We investigated the relationship between social support networks and the use of specific types of health services by HIV-infected drug users receiving methadone maintenance. We found that persons with greater social support, in particular more social network members or more network members aware of their HIV status, were more likely to use primary care services. In contrast, social support networks were not related to emergency room or inpatient hospital use. Interventions that build social support might improve coordinated and continuous health services utilization by HIV-infected persons in outpatient drug treatment.

The social context of homeless men's substance use

BACKGROUND

Homeless men may be at particular risk for the negative health effects of substance use. This cross-sectional study investigates the individual and personal network risk factors associated with substance use in this vulnerable population.

METHODS

Participants were a representative probability sample of 305 heterosexually active homeless men interviewed from meal programs in the Skid Row region of Los Angeles, CA. Interviews assessed individual, personal network, and substance use characteristics. Logistic regression examined individual and personal network predictors of the three most prevalent substances.

RESULTS

In the past 6 months, the three most prevalent substances were marijuana (56%), crack (40%), and alcohol to intoxication (38%). The mental health status of homeless men was associated with substance use, with PTSD more common among those who used crack. Riskier networks (comprised of a larger proportion of drug users) were associated with marijuana use, and normative social ties (family, employed and school/work contacts) were associated with a decreased likelihood of crack use.

CONCLUSIONS

Mental health problems and riskier personal networks are associated with homeless men's substance use. These findings underscore the importance of interventions that focus on improving mental health, mitigating the drug-using norms of personal networks, and helping men to maintain contact with normative, low-risk alters. Mental health care and peer-based, network interventions to reduce substance use should be a priority for heterosexually active homeless men.

Predictors of substance abuse treatment need and receipt among homeless women

Many homeless women do not receive needed treatment for substance abuse. This study identified social network and other predisposing factors associated with perceived need for and receipt of substance abuse treatment among 273 homeless women who screened positive for past-year substance abuse. Perceived treatment need was more likely among women with drug-using sex partners, a denser network, and an arrest history but less likely for those with a minor child and a longer history of homelessness. Receiving treatment was more likely among women who received informational support from their sex partners and who had an arrest history but less likely among those who had a more street-based social network, had a minor child, considered themselves homeless, and recently needed mental health treatment. Treatment services researchers should attend more closely to social contextual factors, as well as the more traditional individual factors, to understand access and barriers to treatment.

The complexities of elder homelessness, a shifting political landscape and emerging community responses

Despite their growing numbers, homeless older adults remain largely invisible in society and there has been a pervasive lack of public focus on elder homelessness. In this article, we seek to shine light on this forgotten population and deepen understanding of difficult challenges they confront in regaining housing security. We also examine the shifting political climate regarding homelessness, particularly the enactment and subsequent reauthorizations of the McKinney-Vento Homeless Assistance Act, and how these shifts are influencing community responses to elder homelessness. Finally, future challenges and policy directions for breaking the cycle of elder homelessness in the U.S. are discussed.

The social context of homeless women's alcohol and drug use

BACKGROUND

Substance use poses a significant threat to the health of women, and homeless women are more likely to use alcohol and drugs than other women. Addressing risk factors in this population requires a focus on the social context of substance use among homeless women.

METHODS

Participants were 445 homeless women who were randomly sampled and interviewed in shelter settings about the characteristics of their personal networks. Binomial logistic regressions predicted days of binge drinking and of using marijuana, crack, cocaine, and methamphetamine or other amphetamines in the past 6 months.

RESULTS

Homeless women with a greater proportion of heavy alcohol users in their personal networks had greater odds of engaging in binge drinking, and women with a greater proportion of drug users in their networks had greater odds of using marijuana, cocaine, crack, and methamphetamine or other amphetamines. Women with a greater proportion of individuals in their networks that they had met in school or through work had lower odds of marijuana, cocaine, and crack use.

CONCLUSIONS

Findings suggest the importance of structural solutions in addressing homeless women's alcohol and drug use, including greater access to treatment and recovery support for alcohol and drug problems as well as depression, and enhancing employment and educational opportunities for homeless women.

Multidimensional social support and the health of homeless individuals

Homeless individuals often suffer from serious health problems. It has been argued that the homeless are socially isolated, with low levels of social support and social functioning, and that this lack of social resources contributes to their ill health. These observations suggest the need to further explore the relationship between social networks, social support, and health among persons who are homeless. The purpose of this study was to examine the association between multidimensional (cognitive/perceived and behavioral/received) social support and health outcomes, including physical health status, mental health status, and recent victimization, among a representative sample of homeless individuals in Toronto, Canada. Multivariate regression analyses were performed on social support and health outcome data from a subsample of 544 homeless adults, recruited from shelters and meal programs through multistage cluster sampling procedures. Results indicated that participants perceived moderately high levels of access to financial, emotional, and instrumental social support in their social networks. These types of perceived social supports were related to better physical and mental health status and lower likelihood of victimization. These findings highlight a need for more services that encourage the integration of homeless individuals into social networks and the building of specific types of social support within networks, in addition to more research into social support and other social contextual factors (e.g., social capital) and their influence on the health of homeless individuals.

Hospitalizations among homeless women: are there ethnic and drug abuse disparities?

This paper explores associations among the vulnerabilities of being female, being a member of a minority group, and being a drug abuser in homeless women's hospitalizations. It uses a 1997 probability survey of 974 homeless females age 15-44 in Los Angeles. In unadjusted analyses, whites were more likely than other ethnic minority groups to be hospitalized, and drug abusers were more likely to be hospitalized than non-drug abusers. Multiple logistic regression analyses indicated that factors associated with hospitalization differed considerably among the ethnic and drug-abuse subgroups. For example, ethnic disparities in inpatient health care were found for drug-abusing women, but not for those who did not abuse drugs. Pregnancy was the only important determinant of hospitalization in all subgroups (OR, 2.9-17.4). Preventing unintended pregnancy appears to be the most inclusive means of reducing hospitalization and attendant costs among homeless women.

Effects of psychosocial and situational variables on substance abuse among homeless adults

Finding direct and indirect influences of salient psychosocial and situational variables on problem substance use among homeless people is important in designing evidence-based, effective, and relevant interventions for this special population. A stress-coping paradigm in conjunction with situational items specialized for homeless people was used to explore predictive relationships in a sample of homeless adults (N = 664) among (a) psychosocial variables of self-esteem, social support, positive and negative coping, and emotional distress, (b) situational variables of homelessness history and quality of recent housing, and (c) outcomes of alcohol use, injection drug use (IDU), and non-IDU. Lower self-esteem predicted greater emotional distress, lower positive coping, greater negative coping, and more alcohol use. Social support predicted less emotional distress and more positive coping. Chronic homelessness predicted more emotional distress, less positive coping, greater alcohol use, and IDU. Poor housing was associated with more alcohol use and IDU. Substance abuse interventions among the homeless should have a dual focus that includes attention to psychological issues and negative coping patterns while also addressing situational, environmental factors, including encouraging provision of permanent supportive housing.

Ladies' night: evaluating a drop-in programme for homeless and marginally housed women in San Francisco's mission district

BACKGROUND

Gender, race, class, and sexuality create a unique set of requirements for addressing HIV risk among homeless and marginally housed (HMH) women. Though studies have recommended both individual and structural prevention strategies tailored to meet the expansive needs of this community, there is a paucity of research on interventions specific to HMH women. Ladies' Night is a service-rich drop-in programme for HMH women in San Francisco's Mission District.

METHODS

In 2006, an exploratory evaluation was conducted to examine the programme's benefits and challenges and identify opportunities to advocate for participants. The evaluation was grounded in ethnography and social network theory. It used three qualitative data collection tools in its methodology: (1) interviews with 5 providers and 8 participants; (2) a self-administered survey completed by 7 participants; and (3) observation field notes from 9 Ladies' Night sessions.

RESULTS

Evaluation findings demonstrate the following: (1) as a harm reduction-based program, Ladies' Night provides safety and social support for programme participants, fosters positive change and promotes health; and (2) the programme has two significant challenges-the social context of participants' lives and resource limitations that affect service provision.

CONCLUSION

Recommendations call for allocation of resources to support: (1) sustainable women-specific services for HMH women in San Francisco; and (2) consistent assessment and evaluation of those services.

An examination of the perceived social support levels of women in methadone maintenance treatment programs who experience various forms of intimate partner violence

BACKGROUND

Intimate partner violence (IPV) has emerged as a serious problem among women in drug treatment programs. Research has underscored the importance of social support for abused women as well as women who use substances.

OBJECTIVES

The main objectives of this study were to describe the perceived social support levels and examine the associations between various forms of IPV and perceived levels of available social support perceived levels among a sample of women in drug treatment programs.

METHODS

Face-to-face, structured interviews were conducted with randomly selected 416 women on methadone.

RESULTS

The prevalence of physical, sexual, and injurious IPV in the sample was 39%, 31%, and 16% respectively, and the combined IPV prevalence was 44.5%. Findings from multiple linear regression models revealed that lower levels of perceived social support were significantly associated with physical aggression (beta = -4.71; p = .0001), sexual assaults (beta = -4.10; p = .003), and injurious attacks (beta = -4.03; p = .022). Respondents perceived highest levels of social support from their "significant others" (mean = 5.64; standard deviation [SD] = 1.27) and lowest levels of social support from friends (mean = 4.20; SD = 1.48). The average network size was 2.7 individuals.

IMPLICATIONS

Findings from this study highlighted significantly lower levels of perceived social support levels for drug-using women in the context of IPV experiences. Interventions with these women should focus on strengthening social support networks that enable help seeking for both IPV and substance abuse issues.

Structural and Personal Factors Related to Access to Housing and Housing Stability among Urban Drug Users in Hartford, Connecticut

Several policies criminalizing drug use significantly impact drug users' access to housing. This article explores the impact of housing policies on active drug users' access to housing and structural and personal factors related to their homelessness and housing stability. Qualitative interviews were conducted with 65 active cocaine or heroin users at baseline, three and six months. Participants were purposively sampled to reflect a variety of housed and homeless statuses. Interviews were analyzed to explore the processes associated with changes in housing status. Factors that led to homelessness included arrest, eviction, absence of housing subsidies, and lack of social support. Participants reported being evicted, and losing housing subsidies, welfare entitlements, and important social relationships following arrest. Criminal histories also limited their ability to find employment and permanent housing. Factors that led to housing stability included having family support, housing subsidies, and social supportive services. Active drug users can maintain independent housing when provided appropriate structural supports including rental subsidies and social services. But arrest disrupts drug users' housing stability. Programs to appropriately house those released from jail could help decrease homelessness among this population.

Efficacy of nurse case-managed intervention for latent tuberculosis among homeless subsamples

BACKGROUND

The efficacy of a nurse case-managed intervention was evaluated in subsamples of participants with one of the following characteristics: female gender, African American ethnicity, recruited from a homeless shelter, a history of military service, lifetime injection drug use, daily alcohol and drug use, poor physical health, and a history of poor mental health.

OBJECTIVE

To determine whether a validated nurse case-managed intervention with incentives and tracking would improve adherence to latent tuberculosis infection treatment in subsamples of homeless persons with characteristics previously identified in the literature as predictive of nonadherence.

METHODS

A prospective 2-group site-randomized design was conducted with 520 homeless adults residing in 12 homeless shelters and residential recovery sites in the Skid Row region of Los Angeles from 1998 to 2003.

RESULTS

Daily drug users, participants with a history of injection drug use, daily alcohol users, and persons who were not of African American race or ethnicity had particularly poor completion rates, even in the nurse case-managed intervention program (48%, 55%, 54%, and 50%, respectively). However, the intervention achieved a 91% completion rate for homeless shelter residents and significantly improved latent tuberculosis infection treatment adherence in 9 of 12 subgroups tested (odds ratios = 2.51-10.41), including daily alcohol and drug users, when potential confounders were controlled using logistic regression analysis.

DISCUSSION

Nurse case management with incentives appears to be a good foundation for increasing adherence to 6-month isoniazid treatment in a variety of homeless subgroups and, in particular, for sheltered homeless populations. However, additional social-structural and environmental strategies are needed to address those at greatest risk of nonadherence.

Unofficial policy: access to housing, housing information and social services among homeless drug users in Hartford, Connecticut

BACKGROUND

Much research has shown that the homeless have higher rates of substance abuse problems than housed populations and that substance abuse increases individuals' vulnerability to homelessness. However, the effects of housing policies on drug users' access to housing have been understudied to date. This paper will look at the "unofficial" housing policies that affect drug users' access to housing.

METHODS

Qualitative interviews were conducted with 65 active users of heroin and cocaine at baseline, 3 and 6 months. Participants were purposively sampled to reflect a variety of housing statuses including homeless on the streets, in shelters, "doubled-up" with family or friends, or permanently housed in subsidized, unsubsidized or supportive housing. Key informant interviews and two focus group interviews were conducted with 15 housing caseworkers. Data were analyzed to explore the processes by which drug users receive information about different housing subsidies and welfare benefits, and their experiences in applying for these.

RESULTS

A number of unofficial policy mechanisms limit drug users' access to housing, information and services, including limited outreach to non-shelter using homeless regarding housing programs, service provider priorities, and service provider discretion in processing applications and providing services.

CONCLUSION

Unofficial policy, i.e. the mechanisms used by caseworkers to ration scarce housing resources, is as important as official housing policies in limiting drug users' access to housing. Drug users' descriptions of their experiences working with caseworkers to obtain permanent, affordable housing, provide insights as to how access to supportive and subsidized housing can be improved for this population.

Impact of marriage on HIV/AIDS risk behaviors among impoverished, at-risk couples: a multilevel latent variable approach

Studies among normative samples generally demonstrate a positive impact of marriage on health behaviors and other related attitudes. In this study, we examine the impact of marriage on HIV/AIDS risk behaviors and attitudes among impoverished, highly stressed, homeless couples, many with severe substance abuse problems. A multilevel analysis of 368 high-risk sexually intimate married and unmarried heterosexual couples assessed individual and couple-level effects on social support, substance use problems, HIV/AIDS knowledge, perceived HIV/AIDS risk, needle-sharing, condom use, multiple sex partners, and HIV/AIDS testing. More variance was explained in the protective and risk variables by couple-level latent variable predictors than by individual latent variable predictors, although some gender effects were found (e.g., more alcohol problems among men). The couple-level variable of marriage predicted lower perceived risk, less deviant social support, and fewer sex partners but predicted more needle-sharing.

A prospective study of risk and protective factors for substance use among impoverished women living in temporary shelter settings in Los Angeles County

Alcohol and drug use are significant public health problems facing homeless women, but few prospective studies have examined risk and protective factors for substance use in this population. This 6-month prospective study identified psychosocial, behavioral, and economic predictors of drinking to intoxication, crack use, and marijuana use in a probability sample of 402 women living in temporary shelter settings in Los Angeles County with a simple majority of homeless residents (92% of these women had a history of homelessness). Engaging in sexual risk behavior and having depressive symptoms were risk factors for more frequent intoxication, marijuana use, and crack use. Drinking to intoxication was additionally predicted by perceived HIV susceptibility, lower social support, more avoidant and less active coping, and lower self-esteem. Additional predictors of marijuana use included partner alcohol misuse and less social support, whereas more frequent crack use was additionally predicted by partner alcohol misuse, lack of economic resources, and more avoidant and less active coping. These findings suggest that effective substance use programs may need an integrative approach that addresses other types of risk behaviors, assists women in strengthening their support networks and learning effective coping skills, and provides access to basic services (e.g., housing, health care). For women in relationships, there may be a further need to address issues of partner substance use.

Predictors of screening results for depressive symptoms among homeless adults in Los Angeles with latent tuberculosis

The purpose of this study was to examine predictors of screening results for depressive symptoms in a Los Angeles homeless population with latent tuberculosis (TB). Four hundred and fifteen homeless adults participating in a nurse case managed intervention were included in this analysis. Logistic regression results indicated that those who reported a physical health limitation, multiple sex partners, daily drug use, alcohol dependence, or not having completed high school, were more likely to screen positive. Social support from non-drug users was protective. Given the importance of adherence to TB treatment regimens, the high prevalence of a positive screening for depressive symptoms in the homeless and the potential for depression to reduce adherence rates, routine screening and treatment for depression in high risk homeless adults being treated for TB may be warranted.

Social support among homeless and housed mothers: an integrative review

Homelessness has been associated with levels of stress beyond the normal strain of living in poverty. For mothers who are homeless, support from their social networks may provide a buffer from some of the stresses associated with being homeless. To better understand the relationship between social support and female-headed homeless families, an integrative review was conducted of 12 research articles that compare social support among low-income housed mothers and homeless mothers, using guidelines set forth by Ganong. The included studies revealed four significant attributes of social support among housed and homeless mothers: size of the social support network; composition of the social support network; contacts with members of the social support network; and perceived support from members of the social support network. Nurses who work with homeless families are in a position to help develop ways for these families to cultivate and maintain their social support networks while homeless. Nurses can be available to offer support, including the necessary mental health services or referrals.

Residential substance user treatment programs as venues for HCV pharmacological treatment: client and staff perspectives

Hepatitis C virus (HCV) infection is highly prevalent among drug users. While there are antiviral medications available to combat the virus, the medication regimen is quite arduous, presenting special issues for drug users. We examined the challenges and benefits of using residential substance user treatment programs as venues for clients to undergo HCV medication regimens. Analyses of qualitative data collected from clients and staff in 2003 at four residential substance user treatment programs in the U.S. indicate that challenges primarily include issues involving the medications' side effects, and both financial and communication concerns. Benefits especially involve clients' feelings that they are being proactive in addressing health issues in an environment that provides much-needed support. Findings illuminate the complex issues involved for both clients and the programs, and some steps that programs can take to better support HCV-infected clients regarding HCV medication concerns.

Predicting positive attitudes about quitting drug and alcohol use among homeless women

Two separate path models for alcohol and drugs were tested in which psychosocial, environmental, and sociodemographic variables predicted behavioral and substance abuse related factors as well as the key outcome of positive attitudes about quitting drugs (N = 620) or alcohol (N = 526) in a sample of 709 homeless women. A positive attitude about quitting alcohol was predicted by more Addiction Symptoms, fewer Positive Effects from using alcohol and not having a partner who uses alcohol. A positive attitude about quitting drugs was predicted by more Drug Problems, greater Drug Use in the Past 6 Months, more Active Coping, more education, less Emotional Distress, not having a partner who uses drugs, and fewer Addiction Symptoms. Implications of the results for drug and alcohol interventions are discussed.

Health disparities among vulnerable populations: evolution of knowledge over five decades in Nursing Research publications

BACKGROUND

Considerable attention has been focused recently on conducting research on the health disparities experienced by some Americans as the result of poverty, ethnicity, and/or marginalized social status. Nursing research has a major role to play in developing this body of knowledge.

PURPOSE

The purpose of this paper is to review the contributions that Nursing Research made through its publications over the last five decades in developing the body of tested knowledge about health disparities in vulnerable groups and to analyze the progress made.

METHODS

Criteria for reviewing the literature were established. All Nursing Research publications between 1952 and 2000 were searched manually, indexes of each year's bound volumes were reviewed, and computer searches were conducted. Included in the review were research reports, research briefs, and methodology articles.

RESULTS

Seventy-nine papers were found that met basic criteria for inclusion. The number of relevant publications increased each decade, with a sizable increase in numbers since 1990, and may be related to the social, political, and economic climate of each decade. The research questions asked and the methods used became more complex over time.

CONCLUSIONS

Nursing Research has made a significant contribution in disseminating the body of tested knowledge related to the health disparities experienced by vulnerable populations and the methodologies associated with vulnerable populations research. Areas for future research are community-based studies, intervention studies that provide tangible resources, and methodologic approaches that involve participants in the research process.

Evaluating the impact of peer, nurse case-managed, and standard HIV risk-reduction programs on psychosocial and health-promoting behavioral outcomes among homeless women

Investigators examined the 6-month impact of three cognitive-behavioral HIV risk-reduction programs on behavioral factors (substance use and sexual risk behaviors) and cognitive and psychological resources of 325 women who resided in emergency or sober-living shelters and their 308 intimate sexual partners. Participants were randomized by shelter to a peer-mentored, a nurse case-managed, or a standard care HIV risk-reduction program. Significant improvements were observed in all groups in all behavioral factors and cognitive and psychological resources except for self-esteem. Participants in the peer-mentored and nurse case-managed groups did not differ significantly from the standard group in self-esteem, life satisfaction, psychological well-being, use of noninjection drugs, sex with multiple partners, and unprotected sex at 6 months (n = 633). It was concluded that a standard approach by health care professionals appears to effectively modify HIV risk behaviors for a majority of homeless participants and may have important economic and policy implications. Further, the impact of short-term programs that address psychological vulnerabilities of impoverished populations needs to be studied further.

Race and ethnicity as variables in Nursing Research, 1952-2000

BACKGROUND

Although the use of race and ethnicity as variables in research has increased over the past five decades, there is confusion regarding the meaning of the terms, as well as how the words are defined and determined in scientific inquiry.

OBJECTIVE

To review the use of race and ethnicity as variables in nursing research literature.

METHODS

Original research articles published in Nursing Research in the years, 1952, 1955, and every 5 years thereafter through 2000 were reviewed. Those articles describing human characteristics (N = 337) were analyzed for content concerning: (a) frequency of racial and ethnic terms, (b) words used for racial and ethnic categories, (c) detinitions of racial and ethnic terms, and (d) how a study participant's race or ethnicity was determined.

RESULTS

Racial and ethnic variables were mentioned in 167 of the 337 reviewed articles. Eighty-one terms and word phrases were used for these variables. In only five articles were the variables defined. Race and ethnic labels were often intermixed and the majority of studies provided no information about how categorization of the participant's race or ethnicity was made. In addition, there was relatively little growth in the number of studies that had racial/ethnic groups, other than Whites, as the majority of the sample.

CONCLUSION

Racial and ethnic variables provide nurse researchers with many challenges. Although race and ethnicity were widely used in Nursing Research articles, the categories were not defined in the majority of papers, and methods used to determine a participant's race or ethnicity were unclear. In order to construct a common and consistent understanding of racial and ethnic categories, nurse researchers should be explicit regarding the rationale related to their use of the categories and the assumptions underlying particular racial and ethnic categorizations.

Sheltered versus nonsheltered homeless women differences in health, behavior, victimization, and utilization of care

OBJECTIVE

To contrast sociodemographic characteristics, physical and mental health status, substance use, sexual behaviors, victimization, and utilization of health services between homeless women residing in sheltered and non-sheltered environments.

DESIGN

Cross-sectional survey. A structured scale was used to measure mental health status. Physical health status, substance use, sexual behavior, history of adult victimization, and health services utilization were measured by content-specific items.

SETTING

Shelters (N = 47) and outdoor locations in Los Angeles.

PARTICIPANTS

One thousand fifty-one homeless women.

RESULTS

Homeless women living on the streets were more likely than sheltered women to be white and longer-term homeless. Controlling for sociodemographic characteristics, multiple logistic regression analyses revealed that unsheltered women had over 3 times greater odds of fair or poor physical health, and over 12 times greater odds of poor mental health than sheltered homeless women. They were also more likely than sheltered women to report using alcohol or noninjection drugs, to have multiple sexual partners, and to have a history of physical assault. About half of the overall sample reported utilization of a variety of health services; however, unsheltered homeless women were less likely to utilize all of the health services that were assessed, including drug treatment.

CONCLUSIONS

There is a critical need for aggressive outreach programs that provide mental health services and substance abuse treatment for homeless women on the streets. Comprehensive services that also include medical care, family planning, violence prevention, and behavioral risk reduction may be particularly valuable for homeless women, especially those living in unsheltered environments.

Personal, cognitive, behavioral, and demographic predictors of HIV testing and STDs in homeless women

Using a multiracial sample of 621 homeless women, we tested a latent variable causal model of personal, cognitive, behavioral, and demographic predictors of two coping mediators and the outcome variables of HIV testing and return for test results and a recent STD infection. HIV testing and return were predicted by more social support, greater AIDS knowledge, greater perceived risk for AIDS, and more problem-focused coping strategies. Recent STDs were predicted by more AIDS knowledge, emotion-focused coping strategies, and risky sexual behavior and one measured variable, crack cocaine use. Emotion-focused coping strategies were predicted by drug use, less self-esteem, more social support, and greater perceived risk for AIDS. Hispanics reported less emotion-focused coping strategies than African-Americans. Predictors of problem-focused coping strategies included less drug use, more self-esteem, more social support, more AIDS knowledge, and less risky sexual behavior. African-Americans reported less problem-focused coping strategies than Latinas. Indirect effects on the outcomes mediated through coping styles are also reported. Theoretical and practical implications of results for community outreach are discussed.